ALN Inferior Vena Cava Filter Upside Down Rotation with Chest Caval Migration in an Asymptomatic Patient

ABSTRACT: Percutaneous placement of an inferior vena cava (IVC) filter is indicated in patients affected by pulmonary embolism or proximal deep venous thrombosis when anticoagulation therapy is contraindicated or there is evidence of thromboembolic recurrence during anticoagulation. Several complications have been reported using IVC filters. Migration is a rare but known and potentially lethal complication of IVC filter placement. In this patient, an ALN IVC filter (ALN Implants Chirurgicaux Ghisonaccia, France) proximal migration occurred from the inferior cava vein to a zone just below the right atrium; it was associated with a complete 180° rotation, and we describe here the procedure employed to successfully remove this filter.

J INVASIVE CARDIOL 2010;22:E153–E155

________________________________________________________
Percutaneous placement of an inferior vena cava (IVC) filter is indicated in patients affected by pulmonary embolism (PE) or proximal deep venous thrombosis (DVT) when anticoagulation therapy is contraindicated or there is evidence of thromboembolic recurrence during anticoagulation. IVC filters span the luminal diameter of the IVC and mechanically trap venous thromboemboli coming from the lower extremities and prevent them from reaching and compromising the pulmonary circulation. Several complications have been reported using IVC filters. Pneumothorax, hemorrhaging, hematomas, DVT, access vein thrombosis and vessel injury — all may result when vascular access is obtained; access site complications range from 2–28%. Filter misplacement is not unusual, occurring in various studies in 1.1–4.6% of cases.^1,3 Minimal IVC migration is a known complication and some kind of movement has been registered in up to 18% of cases.⁴ Complete filter displacement with migration to the heart is a rare complication ranging from 0.1–1.2% and has a variable prevalence, depending on the filter.^5,6 In this case, an ALN IVC (ALN Implants Chirurgicaux Ghisonaccia, France) filter proximal migration occurred from the inferior cava vein to a zone just below the right atrium; it was associated with a complete 180° rotation and here we are describing the procedure used to remove this filter successfully. Case Report. The patient was a 63-year-old female affected by a uterine sarcoma relapse with rectal involvement. In October 2007, she was admitted to the general surgery department of our hospital and underwent proctectomy with colon-anus anastomosis. On the second day after surgery, the patient experienced an episode of syncope followed by dyspnea, hypoxia and hypercapnia. A chest CT scan revealed a massive PE with the presence of emboli in both the right and left lower lobe pulmonary artery branches and in the right middle pulmonary lobe artery branch. For this reason, anticoagulation therapy with low-molecular-weight heparin (LMWH) was initiated. An echocardiographic Doppler showed a DVT in the right femoral vein with a floating aspect, thus we decided to place a retrievable IVC filter. The pre-implant cavogram demonstrated a patent IVC with a maximum diameter of 24 mm. The ALN filter was successfully implanted just below the origin of the renal veins (Figure 1). A new caval venogram after filter placement showed good filter alignment and the absence of any extravasation of contrast material, and the patient tolerated the procedure well. Two weeks later, a control echocardiographic Doppler showed complete resolution of the DVT. Twenty-eight days after implantation, the patient was admitted for the removal of the caval filter. At the beginning of the procedure, an X-ray showed proximal migration of the filter with a complete 180° rotation to the chest inferior caval vein just below the right atrium (Figure 2). The patient was completely asymptomatic. After discussion with the cardiac surgeon, we decided to attempt to remove the filter percutaneously. A first attempt to remove the filter from the right femoral vein was made with an ALN retrieval system made up of a capture device designed to hold the apex of the filter and a large introducer to envelope the device. The filter was hooked in its lateral legs and we succeeded in dislodging the filter into a lower position with its head pointing toward the caval wall. The procedure was terminated and an abdominal CT scan was performed, which showed caval filter migration into the abdominal intrahepatic caval vein with its conic apex turned downward, positioned at 5 mm from the caval wall, with no extravasation of contrast material. The following day, a new procedure was performed both via the right femoral vein and the right internal jugular vein with two ALN retrieval systems (Figure 3A). After several attempts, using the upper retrieval system, we were able to align the filter so that its conic apex was turned downward (Figure 3B). In this way, using the retrieval system coming from the right femoral vein, it was possible to remove the filter. A control caval venogram and a chest-abdomen CT scan showed that the caval vein was free of filling defects, with no evidence of extravasation of contrast material. The patient tolerated the procedure well and was discharged 2 days later in good general condition. Discussion. Although anticoagulation is the treatment of choice for venous thromboembolism, some patients are not suitable candidates for anticoagulation. In these patients, a mechanical interruption of the IVC with a vena cava filter is an alternative or an additional adjunctive procedure. Vena cava filters have been used since 1967 for the prevention of PE, but in recent years, due to the advances in composition and design of the filters, their use has greatly increased. In a recent prospective registry, an IVC filter has been deployed in up to 15% of patients with DVT.⁷ IVC filters can be grouped as follows: permanent, remaining indefinitely with no mechanism for percutaneous removal; temporary, tethered externally and removed within a limited time; or retrievable, designed as permanent devices, but which can be removed in a second procedure if no longer needed. These different kinds of filters, although effective in massive embolic episode prevention, are affected by short- and long-term complications. The adverse event can develop during vascular access, during filter deployment or after the procedure. Complications related to insertion are similar to those that occur during a central venous catheter insertion, that is, hematoma, bleeding, air emboli, arterial puncture and arterio-venous fistula. In the case of a jugular access route, pneumothorax is an important and often life-threatening complication. Another common complication is the misplacement of the filter when delivery takes place in the iliac or renal vein or the suprarenal cava. Congenital vascular anomalies such as IVC duplication or anomalous origin of the renal vein can also lead to incorrect filter placing. Preinsertion cavography can reveal IVC anatomical characteristics and dimensions, thereby facilitating the selection of the size and characteristic of the filter, greatly reducing the rate of misplacement. Excessive tilting of the filter is another potential complication of filter placement. Filter tilt can be due to operator error during delivery or to failure in identifying the location of renal veins or an accessory vein entering the vena cava. During release, filter struts can be deployed in the main vein openings into the IVC, causing filter instability and tilt. Tilt has been correlated to embolic migration after filter placing. Rogers et al,⁸ in a review of prophylactic filter placement in patients with trauma, demonstrated a more frequent incidence of PE in subjects whose filters tilted more than 14 degrees off the longitudinal axis. Excessive filter tilt can cause a loss of contact between the cava wall and the filter hook, allowing emboli to slip past and elude cava interruption. Additional recurrence of PE after filter placement includes a source of embolism from nonprotected territory such as an upper limb, neck and chest, or IVC thrombosis with propagation of thrombus beyond filter struts. IVC wall erosion of filter struts is frequently recorded after filter insertion, but its clinical relevance is not clear. Some authors have reported an unexpectedly high perforation rate with the Bird’s Nest® filter (Cook Medical, Bloomington, Indiana) (85–100%), the Simon Nitinol™ filter (Bard Peripheral Vascular, Tempe, Arizona) (95%) and the Greenfield® filter (Boston Scientific, Natick, Massachusetts) (30%).^9–12 In the great majority of cases, perforation is asymptomatic, but several cases of contiguous organ erosion requiring surgical intervention, such as the aorta and duodenum, have been reported in the literature.^13–15 Migration of IVC filters is a well-recognized, rare and potentially lethal complication. It has a reported incidence of about 3–12%.¹⁶ However, complete filter displacement with migration to the heart is a rare complication, ranging from 0.1–1.2% of cases, with a variable prevalence depending on the filter.^5,6 The symptoms may mimic those of PE and acute myocardial infarction. Several reasons for IVC filter dislodgement have been described and include technical errors, equipment malfunction, mega cava or an increase in IVC diameter from Valsalva maneuvers, poor alignment of the filter with the IVC, J-wire entrapment during central line placement and thrombus pushing the filter proximally.^17–19 The ALN vena cava filter is made of 316 L non-ferromagnetic stainless steel. It is cone-shaped, with two levels of legs. The upper level provides an active anchorage; it consists of shorter strands and has six legs with distal extremities curved into hooks. The lower level consists of three legs, which provide the centering. These legs have a concave curvilinear shape in order to reduce the risk of incorporation of the IVC into the wall. All the legs are unequal in length, thus preventing their intertwining inside the introducer sheath. Few case series have evaluated ALN filter long term adverse events. Pellerin et al20 reported, in a series of 103 patients a 30% incidence of moderate tilting, defined as a deviation from the IVC axis 15°. No case of significant filter migration was noted. Mismetti et al²¹ in a large series of 220 ALN implanted patients demonstrated a 5.7% of filter tilting immediately after deployment. Authors demonstrated a 1.4% rate of filter migration without any case of intracardiac dislodgement as well. A similar rate of tilting without any migration was observed by Caronno et al.²² Imberti et al demonstrated, in a small case series, one case of ALN filter migration reaching the heart.²³ We report the first case ever published in the literature of ALN filter migration to the heart with a complete 180° rotation. In our opinion, the IVC caliber changing due to variation in central venous pressure could have produced a filter-tilting movement. During these oscillations the conical filter edge could have made its way into one of the renal veins reaching a horizontal orientation of the device. Further IVC expansion and centripetal vein blood flow could have produced a complete filter overturning with a cephalic migration.

References

1. Rousseau H, Perreault P, Otal P, et al. The 6-F nitinol TrapEase inferior vena cava filter: Results of a prospective multicenter trial. J Vasc Interv Radiol 2001;12:299–304. 2. Rosenthal D, Wellons ED, Lai KM, et al. Retrievable inferior vena cava filters: Initial clinical results. Ann Vasc Surg 2006;20:157–165. 3. Imberti D, Bianchi M, Farina A, et al. Clinical experience with retrievable vena cava filters: Results of a prospective observational multicenter study. J Thromb Haemost 2005;3:1370–1375. 4. Grassi CJ, Swan TL, Cardella JF, et al. Quality improvement guidelines for percutaneous permanent inferior vena cava filter placement for the prevention of pulmonary embolism. J Vasc Interv Radiol 2001;12:137–141. 5. Athanasoulis CA, Kaufman JA, Halpern EF, et al. inferior vena cava filters: Review of a 26 year single center clinical experience. Radiology 2000;216:54–66. 6. Ferris EJ, Mc Cowan TC, Carver DK, Mc Pharland DR. Percutaneous inferior vena cava filters: follow up of seven designs in 320 patients. Radiology 1993;188:851–856. 7. Goldhaber SZ, Tapson VF, for the DVT FREE Steering Committee. A prospective registry of 5,451patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol 2004;93:259–262. 8. Rogers FB, Strindberg G, Shackford RS, et al. Five–year follow-up of percutaneous vena cava filters in high risk trauma patients. Arch Surg 1998;9:133:406–412. 9. Poletti PA, Becker CD, Prina L, et al. Long-term results of the Simon nitinol inferior vena cava filter. Eur Radiol 1998;8:289–294. 10. Greenfield LJ, Cho KJ, Tauscher JR. Limitations of percutaneous insertion of Greenfield filters. J Cardiovasc Surg (Torino) 1990;31:344–350. 11. Nicholson AA, Ettles DF, Paddon AJ, Dyet JF. Long-term follow-up of the Bird’s Nest IVC Filter. Clin Radiol 1999;54:759–764. 12. Starok MS, Common AA. Follow-up after insertion of Bird’s Nest inferior vena caval filters. Can Assoc Radiol J 1996;47:189–194. 13. al Zahrani HA. Bird's nest inferior vena caval filter migration into the duodenum: A rare cause of upper gastrointestinal bleeding. J Endovasc Surg 1995;2:372–375. 14. Feezor RJ, Huber TS, Welborn MB 3rd, Schell SR. Duodenal perforation with an inferior vena cava filter: an unusual cause of abdominal pain. J Vasc Surg 2002;35:1010–1012. 15. Jörger U, Albrecht D, Ritter R, et al. [Chronic right heart failure after implantation of a cava filter] Dtsch Med Wochenschr 1997;122:1415–1418. 16. Joels CS, Sing RF, Heniford BT. Complications of inferior vena cava filters. Am Surg 2003;69:654–659. 17. Defraigne JO, Vahdat O, Lacroix H, et al. Proximal migration of vena caval filters: Report of two cases with operative retrieval. Ann Vasc Surg 1995;9:571–575. 18. Izutani H, Lalude O, Gill I, et al. Migration of an inferior vena cava filter to the right ventricle and literature review. Can J Cardiol 2004;20:233–235. 19. Mitchell WB, Bonn J. Percutaneous retrieval of a Greenfield filter after migration to the left pulmonary artery. J Vasc Interv Radiol 2005; 16:1013–1017. 20. Pellerin O, Barral FJ, Lions C, et al. Early and late retrieval of the ALN removable vena cava filter: Results from a multi center study. Cardiovasc Intervent Radiol 2008;31:889–896. 21. Mismetti P, Rivron-Guillot K, Quenet S, et al. A prospective long-term study of 220 patients with a retrievable vena cava filter for secondary prevention of venous thromboembolism. Chest 2007;131: 223–229. 22. Caronno R, Piffaretti G, Tozzi M, et al. Mid-term experience with the ALN retrievable inferior vena cava filter. Eur J Vasc Endovasc Surg 2006; 32:596–599. 23. Imberti D, Bianchi M, Farina A, et al. Clinical experience with retrievable vena cava filters: Results of a prospective observational multiceter study. J Tromb Haemost 2005;3:1370–1375.

_________________________________________________________

From the Department of Heart and Vessels, University of Florence, Italy. The authors report no conflicts of interest regarding the content herein. Manuscript submitted September 21, 2009, provisional acceptance given November 3, 2009, final version accepted January 15, 2010. Address for correspondence: Cappelli Francesco, MD, Dept. Heart and Vessels, University of Florence, Viale Morgagni, 85, 50134 Florence, Italy. E-mail: cappellifrancesco@inwind.it